Coding Guideline for sepsis is tricky. For understanding the correct coding for sepsis we have to understand the definition of sepsis, severe sepsis and septic shock. These condition are interrelated. So we need to understand carefully several guideline for sepsis:
Coding of Sepsis
Assign the specific systemic infection code. If type or organism is not identified, assign code A41.9.
Example : Sepsis due to E. coli infection A41.51
In case of negative or inconclusive blood cultures , if there is no evidence of sepsis then condition will not be coded. Provider should be queried.
Urosepsis is similar term. So don’t be confused. Urosepsis and sepsis have separate code. If documents are not cleared then must be queried.
Coding of Severe sepsis
Severe sepsis requires minimum 2 codes :
- Underlying systemic infection
- Severe sepsis R65.2
Assign additional code for organ dysfunction.
Sepsis with organ dysfunction
If sepsis complicated with organ dysfunction then scenario should be coded as severe sepsis. First assigned systemic infection followed by severe sepsis R65.2 and assign additional code for organ dysfunction.
Acute organ dysfunction that is not associated with the sepsis
If patient with HIV has suffered with organ dysfunction but documents don’t support the relation between both condition, then R65.2 never assigned.
Coding of Septic shock
In case of Septic shock following 3 codes needed:
- Underlying systemic infection
- Severe sepsis with septic shock R65.21 or code T81.12 Postprocedural septic shock.
- Additional code of organ dysfunction
Sepsis and severe sepsis with a localized infection
If patient is admitted with localized infection (like pneumonia or cellulitis) and sepsis or severe sepsis :-
Code first underlying systemic infection + R65.2 (if severe sepsis present) + localized infection
If patient is admitted with localized infection and sepsis/severe sepsis doesn’t develop
Code first localized infection + Sepsis/severe sepsis condition
Sepsis due to a post procedural infection
If sepsis occurs due to post procedural infection :
code first post procedural infection + if severe sepsis R65.2 + additional code if organ dysfunction
post procedural infection :-
- T80.2 – Infections following infusion, transfusion, and therapeutic injection
- T81.4 – Infection following a procedure
- T88.0 – Infection following immunisation
- O86.0 – Infection of obstetric surgical wound
Sepsis and severe sepsis associated with a noninfectious process (condition)
A noninfectious condition (like trauma, burn or severe injury etc) sometimes can cause sepsis or severe sepsis. If documents supports the relation between theses condition and sepsis :
Code first the noninfectious condition + code for the resulting infection
If severe sepsis
Code first the noninfectious condition + R65.2 severe sepsis + code for the resulting infection
Bacterial Sepsis of Newborn
P36 : Bacterial sepsis of newborn, includes congenital sepsis
NOTE: If documents doesn’t mentioned congenital or community acquired, the default is congenital and a code from category P36 should be assigned.
P36 code includes the causal organism, an additional code from category:
- B95 – Streptococcus,Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere
- B96 – Other bacterial agents as the cause of diseases classified elsewhere,
should not be assigned.
If the P36 code does not include the causal organism, assign an additional code from category:
B96. If applicable + use additional codes to identify severe sepsis (R65.2-)+ any associated acute organ dysfunction.
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